Epidemiology of adverse drug events and medication errors in four nursing homes in Japan: the Japan Adverse Drug Events (JADE) Study.

BACKGROUND: Worldwide, the emergence of super-ageing societies has increased the number of older people requiring support for daily activities. Many elderly residents of nursing homes (NHs) take drugs to treat chronic conditions; however, there are few reports of medication safety in NHs, especially from non-western countries. OBJECTIVE: We examined the incidence and nature of adverse drug events (ADEs) and medication errors (MEs) in NHs for the elderly in Japan. DESIGN, SETTING, AND PARTICIPANTS: The Japan Adverse Drug Events Study for NHs is a prospective cohort study that was conducted among all residents, except for short-term admissions, at four NHs for older people in Japan for 1 year. MEASUREMENTS: Trained physicians and psychologists, five and six in number, respectively, reviewed all charts of the residents to identify suspected ADEs and MEs, which were then classified by the physicians into ADEs, potential ADEs and other MEs after the exclusion of ineligible events, for the assessment of their severity and preventability. The kappa score for presence of an ADE and preventability were 0.89 and 0.79, respectively. RESULTS: We enrolled 459 residents, and this yielded 3315 resident-months of observation time. We identified 1207 ADEs and 600 MEs (incidence: 36.4 and 18.1 per 100 resident-months, respectively) during the study period. About one-third of ADEs were preventable, and MEs were most frequently observed in the monitoring stage (72%, 433/600), with 71% of the MEs occurring due to inadequate observation following the physician's prescription. CONCLUSION: In Japan, ADEs and MEs are common among elderly residents of NHs. The assessment and appropriate adjustment of medication preadmission and postadmission to NHs are needed to improve medication safety, especially when a single physician is responsible for prescribing most medications for the residents, as is usually the case in Japan.

Over Half of Falls Were Associated with Psychotropic Medication Use in Four Nursing Homes in Japan: A Retrospective Cohort Study.

Medication use can increase the risk of falls and injuries in nursing homes, creating a significant risk for residents. We performed a retrospective cohort study over one year to identify the incidence of drug-related falls with and without injury among four Japanese nursing homes with 280 beds. We evaluated the relationship between potential risk factors for falls and fall-related injuries while considering well-known risks such as ADLs and chronic comorbidities. By collaboratively reviewing care records, we enrolled 459 residents (mean age, 87) and identified 645 falls, including 146 injurious falls and 16 severe injurious falls requiring inpatient care, incidence: 19.5, 4.4, 0.5 per 100 resident-months, respectively. Medication influenced around three-quarters of all falls, >80% of which were psychotropic drugs. Regularly taking ≥5 medications was a risk factor for the initial falls (HR 1.33: CI 1.00−1.77, p = 0.0048) and injuries after falls (OR 2.41: CI 1.30−4.50, p = 0.006). Our findings on the incidence of falls with and without injury were similar to those in Western countries, where the use of psychotropic medication influenced >50% of falls. Discontinuing unnecessary medication use while simultaneously assessing patient ADLs and comorbidities with physicians and pharmacists may help to avoid falls in nursing homes.

Longitudinal Course of Illness in Congenitally Deaf Patient with Auditory Verbal Hallucination.

Auditory verbal hallucination is one of the core symptoms of schizophrenia, same as delusions, and also occurs in many other psychiatric disorders. Significant numbers of people with congenital deafness experience auditory verbal hallucinations; however, there are only a few reports regarding the course of psychosis in people with congenital deafness. Herein, we report the case of a patient with congenital deafness and auditory verbal hallucinations whose diagnosis was changed from psychotic major depression to schizophrenia 7 years after the onset of the disease. His psychotic symptoms decreased when his primary medication was changed from an antidepressant to antipsychotic drugs, based on the change of diagnosis. In the treatment of congenitally deaf patients with auditory verbal hallucinations, the inability to communicate through spoken language may interfere with proper diagnosis and treatment. The ability to collect detailed information in ways other than through verbal language is imperative for psychiatrists to determine the appropriate diagnosis and treatment for these patients during the longitudinal course of illness.

Diagnostic error regarding the cause of cytopenia when increasing psychotropic drugs: Two case reports.

Several psychotropic drugs can cause cytopenia, especially after increasing dosages or initiating treatment. However, cytopenia in patients with psychiatric disorders can also be due to other conditions such as leukemia. In this report, we discuss two cases of cytopenia that occurred during the adjustment of psychotropic medications in patients with severe psychiatric illness. The initial diagnosis in each case was drug-induced cytopenia; however, later, the cause of cytopenia was found to be acute promyelocytic leukemia. When cytopenia is observed while increasing the dosage of psychotropic drugs, suspicious drugs should be discontinued, though the possibility that cytopenia could be due to other reasons should be considered. If there are no signs of recovering blood cells or if cytopenia is severe, psychiatrists should consult hematologists promptly.

Depression Relapse during Long-Term Remission due to Media-Amplified Fear during the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has reoriented societies across the world and placed a significant burden on caring for mental health among its population. In this study, we reported two cases where patients experiencing severe depression with delusions of having COVID-19 required inpatient treatment after long-term remission owing to the negative impact of media reports related to the pandemic. Despite the aggravation of their anxiety, the patients were unable to distance themselves from negative information in attempts to remain informed through media to prevent their families and themselves from being infected. Self-protection through improved media literacy is imperative for people to protect themselves from the fearmongering of the media and infodemic in the present-day scenario.

Antipsychotic Polypharmacy Is Associated With Adverse Drug Events in Psychiatric Inpatients: The Japan Adverse Drug Events Study.

BACKGROUND: Antipsychotic (AP) polypharmacy (APP), the coprescription of more than 1 AP, is frequently practiced in psychiatric inpatients and is considered to be a risk factor for adverse drug events (ADEs). However, the association between APP and ADEs among psychiatric inpatients has not been well investigated. METHODS: The Japan Adverse Drug Events (JADE) study was a series of cohort studies conducted in several clinical settings. In particular, the JADE study for psychiatric inpatients was a retrospective cohort study of 448 psychiatric inpatients with a cumulative 22,733 patient-days. We investigated the relationship between APP, defined as a concurrent prescription of 2 or more APs and ADEs. We also assessed the relationship between potential risk factors for ADEs due to APs. RESULTS: Among the 448 patients included in this study, 106 patients (24%) had APP and the remaining 342 patients were prescribed 1 AP or none. Risperidone was the most frequent drug (25%, 109/442 AP prescriptions) used, and levomepromazine was most frequently prescribed as a concurrent medication with other APs (91%, 29/32). The median number of ADEs among the patients with APP was significantly higher than in those without APP (P = 0.001). Antipsychotic polypharmacy was a risk factor for the occurrence of first (adjusted hazard ratio, 1.54; 95% confidence interval, 1.15-2.04) and second (adjusted hazard ratio, 1.99; 95% confidence interval, 1.40-2.79) ADEs. CONCLUSIONS: Antipsychotic polypharmacy was a risk factor for the occurrence of single and multiple ADEs. Antipsychotic polypharmacy should be conservatively and minimally practiced.

Mild Cognitive Decline Is a Risk Factor for Scam Vulnerability in Older Adults.

Research on elderly financial exploitation has mostly focused on financial abuse that occurs in families and other types of trusted relationships. As such, little is known about financial frauds and scams perpetrated by strangers. Financial fraud and scam prevention activities for older adults must be promoted, for which the correlation between the psychological, social, and cognitive characteristics of their vulnerability needs to be determined. The present study aimed to determine whether cognitive decline is a risk factor for scam vulnerability in older adults. Thus, we created a scam vulnerability scale for older adults with cognitive decline and analyzed the data to reveal the correlation between them, including inhibition and executive function. We conducted an interview survey with 50 older adults with cognitive decline (average age: 79.42 years, SD: 5.44) and 51 older adults without cognitive decline (average age: 76.12 years, SD: 5.82). The interview survey included the scam vulnerability scale, psychosocial questionnaires, and neuropsychological tests. The scale included six items with a four-point Likert scale based on a previous study. Hierarchical multiple regression analysis revealed that lower scores on the Japanese version of the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Jcog; indicating higher general cognitive function) correlated with higher scam vulnerability in the cognitive decline group (ß = -0.46, p < 0.001). In addition, men were found to be more vulnerable in both groups (cognitive decline group: ß = -0.29, p = 0.015, cognitive non-decline group; ß = -0.32, p = 0.018). Inhibition and executive function were found not to correlate significantly with scam vulnerability. These results suggest that mild cognitive decline correlates with higher scam vulnerability, whereas moderate to severe cognitive decline correlates with lower vulnerability, possibly because it makes understanding the scam attempt itself difficult. Older adults with mild cognitive decline and their families, particularly those visiting elderly care or outpatient facilities, should be notified of the scam vulnerability of older clients using the ADAS-Jcog score as an index to help them avoid victimization.

Association between discontinuation of benzodiazepine receptor agonists and post-operative delirium among inpatients with liaison intervention: A retrospective cohort study.

BACKGROUND: Several studies have investigated the association between benzodiazepine receptor agonist (BZDRA) use during the perioperative period and an elevated incidence of delirium. However, no study has focused on the time course of BZDRA use, including continuation, discontinuation, initiation, and no use. This study aimed to examine the influence of the time course of BZDRA use on post-operative delirium. METHODS: This retrospective cohort study was conducted by reviewing medical records. We included patients who were scheduled for surgery under general anesthesia and had been referred to a liaison psychiatrist for pre-operative psychiatric assessment. The patients were classified into four groups based on the pre- and post-operative time course of oral BZDRA use, as follows: continuation, discontinuation, initiation, and no use (never used). The primary outcome was the prevalence of post-operative delirium in non-intensive care unit settings. We also performed stratified analyses according to age, the presence of cognitive impairment, the presence of delirium history, and antipsychotic drug use on admission. RESULTS: Among 250 patients, 78 (31%) developed post-operative delirium. The Discontinuation group had a higher rate of delirium (49%, 24/49) than the other groups (Continuation [14%, 4/29]; Initiation [38%, 3/8], Never used [29%, 47/164], p = 0.008). CONCLUSIONS: Abrupt discontinuation of BZDRAs during the perioperative period may be a risk factor for post-operative delirium and should therefore be avoided.

Individual Differences in Interoceptive Accuracy Are Correlated With Salience Network Connectivity in Older Adults.

Interoceptive accuracy refers to the ability to consciously perceive the physical condition of the inner body, including one's heartbeat. In younger adults, interoceptive accuracy is correlated with insular and orbitofrontal cortical connectivity within the salience network (SN). As interoceptive accuracy and insular cortex volume are known to decrease with aging, we aimed to evaluate the correlation between SN connectivity and interoceptive accuracy in older adults. 27 older adults (mean age, 77.29 years, SD = 6.24; 19 female) underwent resting-state functional magnetic resonance imaging, followed by a heartbeat counting task and neuropsychological test. We evaluated the correlation between interoceptive accuracy and SN connectivity with age, sex, cognitive function, and total gray matter volume as covariates. Region of interest-to-region of interest analyses showed that interoceptive accuracy was positively correlated with the functional connectivity (FC) of the left rostral prefrontal cortex with the right insular, right orbitofrontal, and anterior cingulate cortices [F(6,16) = 4.52, false discovery rate (FDR)-corrected p < 0.05]. Moreover, interoceptive accuracy was negatively correlated to the FC of the left anterior insular cortex with right intra-calcarine and visual medial cortices (F(6,16) = 2.04, FDR-corrected p < 0.10). These findings suggest that coordination between systems, with a positive correlation between left rostral prefrontal cortex and the SN and a negative correlation between left insular cortex and vision-related exteroceptive brain regions, is important for maintaining interoceptive accuracy in older adults.

Frequency and predictors of perioperative psychiatric symptom worsening among patients with psychiatric disorders.

OBJECTIVE: This study aimed to clarify the frequency of perioperative psychiatric symptom worsening among patients with psychiatric disorders and investigate factors predictive of symptom aggravation. METHOD: This study adopted a retrospective cohort study design. The sample consisted of perioperative inpatients who were diagnosed with psychiatric disorders on admission and received psychiatric intervention between January 1, 2015 and November 31, 2017. RESULTS: Of 176 inpatients who met our inclusion criteria, 15 (8.5%) exhibited symptom worsening. Factors associated with symptom worsening included changes in surface morphology during surgery (p<0.01; odds ratio (OR)=10.58; 95% confidence interval (CI), 3.40-32.87), otolaryngological surgery (p=0.01; OR=6.95; 95% CI, 1.81-26.75), stay in the intensive care unit (p<0.01; OR=5.65; 95% CI, 1.79-17.81), and surgery duration longer than 180min (p=0.03; OR=3.40; 95% CI, 1.04-11.13). CONCLUSION: This was the first retrospective analysis to focus on the perioperative worsening of psychiatric symptoms. As only few inpatients exhibited symptom aggravation, general hospitals without psychiatric beds can receive perioperative patients with psychiatric comorbidity. However, caution should be exercised to address the potential worsening of symptoms in cases of surface-morphology changing surgery, otolaryngological surgery, long-duration operations, and when ICU stay is required.

A Case of Fetal Tachycardia after Electroconvulsive Therapy: A Possible Effect of Maternal Hypoxia and Uterine Contractions.

Electroconvulsive therapy (ECT) is considered to be an effective and safe treatment for depression in pregnant women in that it avoids the risk of psychotropic pharmacotherapy. However, clinicians should be cautious about the adverse effects in the fetus, such as fetal cardiac arrhythmia. Most of the previous studies have demonstrated a reduction in fetal heart rate associated with ECT. However, we encountered a case of fetal tachycardia after maternal ECT-induced convulsions. The patient was a woman who was 30 weeks' pregnant and had severe depression; fetal tachycardia (180-200 bpm) occurred immediately after the electrical stimulation and lasted for more than 30 minutes. The fetal tachycardia might have been caused by maternal hypoxia and uterine contractions. To our knowledge, this is the first report of fetal tachycardia as an adverse effect of ECT. Prolonged fetal tachycardia may cause fetal heart failure. Therefore, oxygenation during convulsions and careful fetal cardiac monitoring are essential when administering ECT in pregnancy.

The epidemiology of adverse drug events and medication errors among psychiatric inpatients in Japan: the JADE study.

BACKGROUND: Knowledge of the epidemiology of adverse drug events (ADEs) and medication errors in psychiatric inpatients is limited outside Western countries. The nature of ADEs and medication errors are important for improving the quality of care worldwide; therefore, we conducted the Japan Adverse Drug Events Study, a series of cohort studies at several settings in Japan. METHODS: This report included 448 inpatients with 22,733 patient-days in a psychiatric hospital and psychiatric units at a tertiary care teaching hospital over 1 year. Four psychiatrists and two other physicians reviewed all medical charts and related documents to identify suspected incidents. The physicians later classified those incidents into ADEs, potential ADEs, medication errors, or exclusions and evaluated the severity and preventability if the incidents were events. RESULTS: During the study period, we identified 955 ADEs and 398 medication errors (incidence: 42.0 and 17.5 per 1000 patient-days, respectively). Among ADEs, 1.4 %, 28 %, and 71 % were life-threatening, serious, and significant, respectively. Antipsychotics were associated with half of all ADEs. The incidence of medication errors was higher in medical care units than in acute and nursing care units (40.9, 15.6, and 17.4 per 1000 patient-days, respectively). The monitoring and ordering stages were the most common error stages (39 % and 34 % of all medication errors, respectively), and 76 % of medication errors with ADEs were found at the monitoring stage. Non-psychiatric drugs were three times as likely to cause ADEs with errors compared to psychiatric drugs. CONCLUSIONS: Antipsychotic use, inadequate monitoring, and treatment of physical ailments by psychiatrists may contribute to the high incidence of medication errors and ADEs among psychiatric inpatients in Japan. Psychiatrists should be cautious in prescribing antipsychotics or unfamiliar medications for physical problems in their psychiatric patients, and should monitor patients after medication administration.

Treatment in a ward for elderly patients with dementia in Japan.

BACKGROUND: Japan has become the world's most aged country. The percentage of elderly people in Japan is estimated to reach 25.2% in 2013, and the number of patients with dementia is estimated to reach 2.5 million in 2015. In addition to its deterioration of physical function and activities of daily living (ADL), behavioral and psychological symptoms of dementia (BPSD) often become major clinical problems, greatly annoying patients and their caregivers. In Japan, we utilize wards for elderly patients with dementia (WEDs) for BPSD treatment. However, there are few studies investigating the effectiveness of treatment in a WED. In such treatment, physical complications are a challenge physicians must overcome while treating BPSD and safely returning patients home or to the institutions in which they live. Therefore, we investigated the effectiveness of treatment in a WED, focusing on physical complications. METHODS: The subjects were 88 patients who were admitted to and discharged from a WED. Severity of dementia, basic ADL, and BPSD were investigated using the Clinical Dementia Rating, Physical Self-Maintenance Scale (PSMS), and Neuropsychiatric Inventory. Differences in characteristics between patients discharged from the WED because of physical complications and all other patients were also examined. RESULTS: We found significant improvements in the PSMS score and decreases in delusions and sleep disturbances in all patients. Patients discharged from the WED because of physical complications had significantly greater severity of dementia at discharge compared to all other patients. CONCLUSION: Treatment in a WED seems to be effective for BPSD and ADL, but care should be taken regarding physical complications, especially in patients with advanced dementia.